Topographic anatomy of the pelvic organs. pelvic diaphragm

D. N. Lubotsky

24.1. general information

Under the name "pelvis" in descriptive anatomy, they understand that part of the body that is limited by the bones of the pelvic ring. Its upper part is formed by the ilium and forms a large pelvis, in which the organs of the abdominal cavity are located: in the right iliac fossa - the caecum with the terminal ileum and appendix, in the left iliac fossa - the sigmoid colon. Below the border line (linea terminalis) begins the small pelvis. The study of the relationship of the pelvic organs is the subject of topographic anatomy. In the following, the small pelvis will be referred to as the "pelvis" for brevity.

Soft tissues covering the pelvic bones from the outside are usually referred to other areas: for example, mm. glutei, end sections mm. piriformis and obturatorius internus belong to the gluteal region, the final section m. iliopsoas and initial division m. obturatorius externus - to the deep parts of the anterior region of the thigh. The exit from the pelvis is closed by soft tissues that make up the perineum.

External landmarks relating to the pelvis and perineum have already been described in the presentation of the topography of other areas. Here, in addition, the lower edge of the symphysis and the pubic arch should be noted, which can be palpated in men behind the scrotal root. In women, the lower edge of the pubic fusion, as well as the pelvic cape (promontorium), is determined during vaginal examinations.

Determination of the configuration and condition of the pelvic organs is carried out from the side of the rectum with the index finger of the right hand inserted into the anus, and in women - also from the side of the vagina with the index and middle fingers and at the same time with the left hand through the anterior abdominal wall (the so-called two-handed, bimanual, study) .

24.2. Bone-ligamentous base,
musculature of the walls and floor of the pelvis

The bone base of the pelvis is made up of two pelvic bones, the sacrum, the coccyx and the fifth lumbar vertebra. Each pelvic bone consists of the ilium, ischium, and pubic bones. The ilium with the sacrum form two inactive sacroiliac joints; the pubic bones are connected to each other in front immovably by means of fibrous cartilage (symphysis ossium pubis; sumphysis pubica - PNA). The bones of the pelvis as a whole are articulated by their acetabulum with the femur bones (hip joints).

Two powerful ligaments connect the sacrum (on each side) with the ilium and ischium: lig. sacrospinal and lig. sacrotuberale. Both ligaments and ischia-

Rice. 24.1. Diaphragm of the pelvis of a woman (according to Lipmann, with changes):

1 - diaphragma urogenitale; 2 - vasa obturatoria and n. obturatorius; 3 - m. obturatorius internus; 4 - arcus tendineus m. Levatorisani; 5-m. levator ani; 6- anus; 7- vasa glutea superiora and n. gluteus superior; 8- nn. ischiadicus and cutaneus femoris; posterior, vasa glutea inferiora and n. gluteus inferior, vasa pudenda interna and n. pudendus; 9- m. piriformis; 10 - m. coccygeus; 11 - lig. anococcygeum; 12- centrum perineale; 13 - vagina; 14- urethra

naja awn turn two notches available on the pelvic bone into two holes - a large and small sciatic foramen, through which muscles, vessels and nerves pass.

The composition of the pelvic walls, in addition to bones, includes parietal muscles, a significant part of which belongs to the gluteal region.

From the anterior surface of the sacrum, the piriformis muscle (m. piriformis) begins, which passes through the large sciatic foramen. Above and below the muscle there are slit-like openings (foramen supra- et infrapiriforme), through which the vessels and nerves pass.

From the edges of the obturator foramen, on the inner surface of the pelvic bone, m begins. obturatorius internus; this muscle passes through the lesser sciatic foramen. In the pelvis is the visceral (visceral) group of muscles that are directly related to the insides of the pelvis. This is primarily a paired muscle that raises the anus (m. levator ani) and the external sphincter of the anus (t. sphincter ani externus). M. levator ani has a triangular shape and is composed of two muscles: anterior (m. pubococcygeus) and posterior (m. Shosos-cygeus). Both of them start from the inner surface of the pelvic bones (the first from the pubic bone, the second from the ilium), as well as from the thickened part of the pelvic fascia (arcus tendineus fasciae pelvis). The fibers of the right and left muscles - the anus lifters - form a kind of funnel, tapering downwards. These fibers are located on the sides of the organs of the genitourinary system.

Rice. 24.2. Male urogenital diaphragm (according to Callender, with changes): 1 - symphysis publica; 2 - lig. arcuatum pubis; 3 - v. dorsalis penis; 4 - n. and a. dorsalis penis; 5 - lig. transversum perinei (cut from above to show the position of the neurovascular bundles); 6, 11 - m. transversus perinei profundus; 7, 12 - fascia diaphragmatis urogenitalis interior; 8 - fascia diaphragmatis urogenitalis superior; 9 - urethra and T. sphincter urethrae (memoranaceae - BNA); 10 - glandula bulbourethralis (Cowperi)

and partly intertwined with the muscles of the rectum and other pelvic organs, partly cover the rectum from behind and attach to the coccyx by means of lig. anococcygeum.

Pelvic diaphragm. The muscles that form the floor of the pelvic cavity, together with their fascia, constitute the so-called pelvic diaphragm. This includes both muscles that lift the anus, and the coccygeal muscles located behind them (mm. coccygei) (Fig. 24.1).

Urogenital diaphragm. The anterior parts of the muscles that lift the anus do not close with their inner edges; in the space between them under the pubic arch is the so-called urogenital diaphragm (diaphragma urogenitale). This name is understood as a dense muscular-fascial plate, consisting of a deep transverse muscle of the perineum and two fascial sheets covering the muscle from above and below (Fig. 24.2).

The deep transverse muscle of the perineum performs the angle formed by the lower branches of the pubic and ischial bones. The muscle, however, does not reach the pubic fusion and is separated from it by two ligaments. One of them is lig. transversum perinei - formed by both fascial plates that cover the muscle on both sides and converge anterior to it; the other is lig. arcuatum pubis - goes along the lower edge of the symphysis. Between both ligaments passes the dorsal vein of the penis or clitoris in women (Fig. 24.3).

The urethra passes through the urogenital diaphragm in men and the urethra and vagina in women. The final section of the rectum passes through the diaphragm of the pelvis.

24.3. Fascia of the pelvis

The walls and insides of the small pelvis are covered with pelvic fascia (fascia pelvis). It is a continuation of the visceral fascia of the abdomen and, by analogy with it, is called the visceral fascia of the pelvis (fascia endopelvina). It is customary to distinguish between two sheets of the pelvic fascia - parietal and visceral. The first lines the walls and bottom of the pelvic cavity, the second covers the organs of the pelvis (see Fig. 24.3).

On the border of the upper and lower halves of the obturator internus muscle, the parietal sheet of the pelvic fascia forms a thickening - a tendon arc (arcus tendineus fasciae pelvis). M starts from it. levator ani, the upper surface of which is covered by the pelvic fascia. In the posterior part of the pelvic floor, the fascia covers t. piriformis.

Between the symphysis and the prostate gland in men (or between the symphysis and bladder in women), the pelvic fascia forms two thick sagittally directed folds or ligaments - ligamenta puboprostatica (ligamenta pubovesicalia - in women).

Moving on to the organs, the pelvic fascia gives two spurs located in the sagittal plane between the pubic bones and the sacrum. Thus, the pelvic organs are enclosed in a space bounded in front by the pubic bones, behind - by the sacrum and coccyx, from the sides - by the sagittal plates of the pelvic fascia. This space is divided into two sections - anterior and posterior - by a special partition located in the frontal plane between the bottom of the peritoneal sac and the urogenital diaphragm. The septum is formed by the peritoneal-perineal aponeurosis (aponeurosis peritoneoperinealis), otherwise the Denonvilliers aponeurosis 1, which represents a duplication of the primary peritoneum. The periperineal aponeurosis separates the rectum from the bladder and prostate gland, so that the anterior part of the space in men contains the bladder, prostate gland, seminal vesicles and ampullae of the vas deferens, and in women - the bladder and vagina; the posterior section contains the rectum. Due to the pelvic fascia and the Denonvillier aponeurosis, all of these organs receive fascial cases, with the Pirogov-Retzius capsule for the prostate gland and the Amusse capsule for the rectum being especially distinguished.

Occupying a middle position in the small pelvis, the organs nowhere directly touch the walls of the pelvis and are separated from them by fiber. Where these organs are deprived of the peritoneal cover, they are covered by the visceral sheet of the pelvic fascia, but between the fascia and the organ there is fiber containing the blood and lymphatic vessels and nerves of the organ. Us. 652 the main cellular spaces surrounding the pelvic organs are considered.

24.4. The ratio of the peritoneum to the pelvic organs

Moving to the anterior abdominal wall on the anterior and upper walls of the bladder, the peritoneum forms a transverse cystic fold (plioca vesicalis transver-

1 Denonville's aponeurosis, consisting of two sheets, is also called rectovesical fascia (fascia rectovesicalis), or septum (septum rectovesicale), in men and rectovaginal fascia, or septum (fascia rectovaginalis, s. septum rectovaginale), in women. According to L.P. Krayzelburd, the Denonville aponeurosis ends on the posterior wall of the rectum.

sa), located closer to the symphysis with an empty bladder. Further, in men, the peritoneum covers part of the lateral and posterior walls of the bladder, the inner edges of the ampullae of the vas deferens and the tops of the seminal vesicles (the peritoneum is 1.0-1.5 cm from the base of the prostate gland). Then the peritoneum passes to the rectum, forming the rectovesical space, or notch, - excavatio rectovesicalis. From the sides, this recess is limited by the rectovesical folds of the peritoneum (plica rectovesicales), located in the anteroposterior direction from the bladder to the rectum. They contain fibrous and smooth muscle fibers, partly reaching the sacrum.

In the rectovesical notch, part of the loops of the small intestine, sometimes the transverse colon or sigmoid colon, can be placed. It should be noted, however, that the deepest part of the rectovesical space is a narrow gap; intestinal loops usually do not penetrate into this gap, but effusions can accumulate in it.

With an average degree of filling of the bladder, the bottom of the rectovesical space in men is located at the level of the sacrococcygeal joint and is separated from the anus by an average of 6 cm 1.

In women, when the peritoneum passes from the bladder to the uterus, and then to the rectum, two peritoneal spaces (recesses) are formed: the anterior - excavatio vesicouterina (vesico-uterine space) and the posterior - excavatio rectoute-rina (rectal-uterine space) 2.

When moving from the uterus to the rectum, the peritoneum forms two lateral folds that stretch in the anteroposterior direction and reach the sacrum. They are called recto-uterine folds (plicae rectouterinae) and contain ligaments consisting of muscle-fibrous bundles (m. rectouterinus).

A greater omentum may be placed in the vesicouterine space; in the recto-uterine space, with the exception of its narrow part, there are loops of the small intestines. At the bottom of the excavatio rectouterina, blood, pus, and urine can accumulate during injuries and inflammations; it can be penetrated (for example, by a puncture) from the posterior fornix of the vagina.

24.5. Three sections of the pelvic cavity

The pelvic cavity is divided into three sections, or floors: cavum pelvis peritoneale, cavum pelvis subperitoneale and cavum pelvis subcutaneum (Fig. 24.5).

The first section - cavum pelvis peritoneale - represents the lower part of the abdominal cavity and is limited (conditionally) from above by a plane passing through the pelvic inlet. It contains those organs or parts of the pelvic organs that are covered by the peritoneum. In men, in the peritoneal cavity of the pelvis, the part of the rectum covered by the peritoneum is located, and then the upper, partially posterolateral and, to a small extent, the anterior walls of the bladder.

In women, in the first floor of the pelvic cavity, the same parts of the bladder and rectum are placed as in men, most of the uterus and its appendages (ovaries and fallopian tubes), wide uterine ligaments, as well as the uppermost part of the vagina (for 1 -2 cm).

1 If there is an accumulation of pus or blood in this space, it can be emptied by
a stake through the rectum.

2 This space is also called Douglas space. In gynecology, both spaces are often
called Douglas: vesicouterine - anterior Douglas, recto-uterine -
posterior Douglas space.

Rice. 24.5. Three floors of the pelvic cavity (diagram of a frontal incision through the rectum):

1 - cavum pelvis peritoneale; 2 - cavum pelvis subperitoneale; 3 - cavum pelvis subcutaneum (resp. fossa ischiorectalis); 4 - fascia obturatoria and canalis pudendalis formed by it, containing vasa pudenda interna and n. pudendus; 5-m. levatorani with sheets of pelvic fascia covering the muscle; 6- m. obturatorius interims; 7-peritoneum

The second section - cavum pelvis subperitoneale - is enclosed between the peritoneum and the sheet of the pelvic fascia covering m. levator ani on top (see fig. 24.5). Here, in men, there are the extraperitoneal sections of the bladder and rectum, the prostate gland, seminal vesicles, the pelvic sections of the vas deferens with their ampullae, and the pelvic sections of the ureters.

In women, in this floor of the pelvic cavity there are the same sections of the ureters, bladder and rectum as in men, the cervix, the initial section of the vagina (with the exception of a small area covered by the peritoneum) 1. The organs located in the cavum pelvis subperitoneale are surrounded by connective tissue cases formed by the pelvic fascia (see p. 648).

In addition to the listed organs, blood vessels, nerves, and lymph nodes are located in the fiber layer between the peritoneum and the pelvic fascia.

The third section - cavum pelvis subcutaneum - is enclosed between the lower surface of the pelvic diaphragm and integuments. This section belongs to the perineum and contains parts of the organs of the genitourinary system and the final section of the intestinal tube. This also includes the fat-filled fossa ischiorectalis, located on the side of the perineal rectum (see Fig. 24.5).

1 Part of the subperitoneal space of the pelvis (cavum pelvis subperitoneale), enclosed between the rectum and m. levator ani, in surgery and gynecology is often referred to by the term cavum pelvirectale(pelvirectal space).

24.6. Vessels, nerves and lymph nodes of the pelvis

The internal iliac artery (a. iliaca interna), otherwise the hypogastric artery (a. hypogastrica - BNA), arises from the common iliac at the level of the sacroiliac joint and goes downward, outwards and backwards, located on the posterolateral wall of the pelvic cavity. The accompanying vein runs posterior to the artery. The trunk of the artery is usually short (3-4 cm) and, at the level of the upper edge of the large sciatic foramen, is divided into two large branches - the anterior and posterior, from which the parietal and visceral arteries arise. The first go to the walls of the pelvis, the second - to the pelvic viscera and external genital organs. From the posterior branch of a. iliaca interna, only parietal arteries arise, from the anterior - mainly visceral.

The parietal veins accompany the arteries in the form of paired vessels, the visceral veins form massive venous plexuses around the organs: pi. venosus rectalis (pi. haemorrhoidalis - BNA), pi. venosus vesicalis, pi. venosus prostati-cus (pi. pudendalis - BNA), pi. venosus uterinus, pi. venosus vaginalis. Blood from these plexuses flows into the internal iliac vein and partially (from the rectum) into the portal vein system.

The sacral nerve plexus (plexus sacralis) lies directly on the piriformis muscle. It is formed by the anterior branches of the IV and V lumbar nerves and I, II, III sacral, exiting through the anterior sacral openings (see Fig. 23.5). The nerves arising from the plexus, with the exception of short muscle branches, are sent to the gluteal region through the foramen suprapiri- forme (n. gluteus superior with vessels of the same name) and foramen mfrapiriforme (n. gluteus inferior with vessels of the same name, as well as n. cutaneus femoris posterior, n. ischiadicus). Together with the last nerves, p. pudendus comes out of the pelvic cavity, accompanied by vessels (vasa pudenda interna). This nerve arises from the plexus pudendus, which lies at the lower edge of the piriformis muscle (under the sacral plexus) and is formed by the II, III and IV sacral nerves. Along the side wall of the pelvis, below the border line, passes the p. obturatorius (from the lumbar plexus), which, together with the vessels of the same name, penetrates into the canalis obturatorius and through it into the bed of the conducting muscles of the thigh (see Fig. 23.5).

Along the inner edge of the anterior sacral openings lies the sacral section of the sympathetic trunk, and outward from it, the anterior branches of the sacral nerves emerge, forming the sacral plexus (see Fig. 23.5).

The main sources of innervation of the pelvic organs are the right and left trunks of the sympathetic nerve (their branches are called nn. hypogastrici dexter et sinister) and II, III and IV sacral nerves, which give parasympathetic innervation (their branches are called nn. splanchnici pelvini, otherwise - nn. erigentes ) (see Fig. 24.16). The branches of the sympathetic trunks and the branches of the sacral nerves, as a rule, are not directly involved in the innervation of the pelvic organs, but are part of the hypogastric plexuses, from which secondary plexuses arise that innervate the pelvic organs.

There are three groups of lymph nodes in the pelvis: one group is located along the external and common iliac arteries, the other - along the internal iliac artery, the third - on the anterior concave surface of the sacrum. The first group of nodes receives lymph from the lower limb, superficial vessels of the gluteal region, the walls of the abdomen (their lower half), the superficial layers of the perineum, from the external genitalia. The internal iliac nodes collect lymph from most of the pelvic organs and formations that make up the pelvic wall. The sacral nodes receive lymph from the posterior wall of the pelvis and from the rectum.

The node lying in the bifurcation of the common iliac artery is designated as lymphonodus interiliacus. There are two lymph currents from the pelvic organs and from the lower limb.

The afferent vessels of the iliac nodes are sent to the nodes lying at the inferior vena cava (right) and the aorta (left). Some of these vessels are interrupted in the so-called subaortic nodes, which lie at the level of the aortic bifurcation near the right and left common iliac arteries.

Both in the male and in the female pelvis, the presence of direct and indirect connections between the efferent lymphatic vessels of various organs is noted.

24.7. Cellular spaces of the pelvis

The fiber of the pelvis separates the organs enclosed in it from the walls of the pelvis and is also enclosed between the organs and the fascial cases surrounding them. The main cellular spaces of the pelvic cavity are located on the middle floor of its cavum subperitoneale (see Fig. 21.34, 21.35).

In the lateral sections of the pelvis, on both sides of the parietal sheet of the pelvic fascia, there is fiber of the parietal space, and outward from the parietal sheet are large nerve trunks that form the sacral plexus, and inside - large vessels (internal iliac). This fiber also accompanies the vessels and nerves that go to the internal organs of the pelvis and to neighboring areas: through the foramen infrapiriforme, along the lower gluteal vessels and nerve, it has a connection with the fiber of the gluteal region, and further along the sciatic nerve - with the fiber of the back of the thigh . Through the canalis obturatorius, the parietal space of the pelvis communicates with the tissue of the bed of the adductor muscles of the thigh.

Behind the symphysis and anterior to the bladder is the practically important prevesical space (spatium prevesicale), often called the Retzian space, and according to BNA - spatium retropubicum (rear pubic space). It is bounded from below by the puboprostatic (or pubovesical) ligaments. It should be emphasized at the same time that anterior to the bladder there is not one cellular space, but two: pre-bladder and pre-peritoneal. The presence of two spaces is due to the existence of a special fascia - prevesical, covering the anterior surface of the bladder. The fascia has the form of a triangular plate, the lateral edges of which reach the obliterated umbilical arteries, and the apex ends in the region of the umbilical ring. Thus, between the transverse fascia of the abdomen, attached to the upper edge of the symphysis, and the prevesical fascia, a prevesical space is formed, and between the prevesical fascia and the peritoneum, the preperitoneal space of the bladder (see Fig. 24.18).

In the prevesical space, hematomas can develop with pelvic fractures; with damage to the bladder, urinary infiltration may occur here. Since the integrity of the prevesical fascia is also violated during an extraperitoneal rupture of the bladder, urinary infiltration spreads upward along the preperitoneal tissue of the anterior abdominal wall (see Fig. 21.45).

From the sides, the prevesical space passes into the perivesical (spatium par-avesicale), reaching the internal iliac vessels (Fig. 24.6).

In case of violation of the integrity of the prevesical fascia near the internal iliac vessels, the purulent process from the perivesical space can spread to the tissue of the parietal space of the pelvis, and from there to the retroperitoneal tissue of the iliac fossa.

The posterior rectal cellular space (spatium retrorectale) is located behind the ampulla of the rectum and its capsule, is bounded behind by the sacral bone, and below by the fascia covering m. levator

Ultrasound procedure ( ) pelvic organs is one of the main methods for diagnosing causes. Its undeniable advantages are low cost, the absence of side effects and obvious contraindications, as well as a rather high information content. It should be borne in mind that ultrasound is not the only diagnostic method, and in order to confirm the causes of infertility, it is necessary to undergo a number of additional laboratory tests.

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Ultrasound examination is a method, the results of which largely depend on the experience and skills of the diagnostician, since the diagnosis and, accordingly, the subsequent treatment tactics depend on the correct interpretation of the symptoms and signs visible on the monitor. It is important during the study to talk with a doctor, since the clarification of some life details allows you to exclude or, conversely, to assume certain pathological abnormalities.

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Infertility is a pathological situation in which a couple who does not use any methods of contraception cannot for 12 months. This pathology is quite common and occurs with a frequency of 10 to 15% among couples of reproductive age. According to statistics, the cause of infertility can be equally likely to be both male and female. Ultrasound is a fairly informative method for diagnosing most causes of female infertility. However, it should be understood that ultrasound is effective only in detecting existing structural anomalies, the scale of which corresponds to the resolution of the apparatus. Hormonal disorders, functional changes in the genital organs, disruption of the hormonal-nervous system responsible for cyclic changes and maintenance, the presence of antibodies to the partner's sperm, as well as a number of other pathologies cannot be detected using echography ( ultrasound). These diseases, as well as male infertility, need a detailed laboratory study, which is more informative in such situations.

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What female organs are located in the pelvis?

The female reproductive organs can be divided into internal and external. The external genitals are in direct contact with the external environment, while the internal ones are protected from this. In addition, all internal genital organs are located in the pelvic cavity.

Almost a third of women experience involuntary urination. Urinary incontinence is the involuntary flow of urine of varying degrees. It hurts twice as often as men. However, those who laugh to tears or when exercising sometimes have to get wet on the spot, do not be upset - this problem is solved. Modern technologies allow the treatment of urinary incontinence using a non-invasive laser method. We're talking gynecologist Inese Zeima.

What causes urinary incontinence in women? Urinary incontinence is several times more common in women than in men. The most common causes are pregnancy and childbirth. Postpartum pelvic reciprocal position changes, so more childbirth, the more likely to encounter the problem of urinary incontinence. It also depends on obesity, various diseases, natural aging and genetics.

External female genital organs include:

• Crotch. The perineal region, which in some cases can be considered outside the genital complex, is nevertheless an extremely important structure. This is due to the fact that in this region there is a layer of muscles that form the bottom of the small pelvis, and whose role is extremely high during pregnancy and. In addition, the normal functioning of the urinary and digestive systems depends on the force of contraction of these muscles, or rather, on their tone, since excessive contraction can make it difficult to pass urine and feces, and excessive relaxation can lead to their incontinence.
• Pubis. The pubis is a slightly rounded area located above the labia majora and slightly anterior to the pubic pelvic bone. During puberty, pubic hair is formed.
• Large labia. The labia majora are represented by two voluminous longitudinal folds, which consist of adipose and connective tissue covered with skin. Their size and shape may vary slightly in different women, depending on the constitution, as well as on the thickness of the subcutaneous fatty tissue. In the skin of the labia are hair follicles, which, as puberty forms the hairline.
• Small labia. The labia minora are two small longitudinal skin folds that are located between the labia majora and the entrance to the vagina. In front of the labia minora, connecting, form the frenulum of the clitoris ( thin folds of skin extending from the clitoris).
• Hymen. The hymen is a thin connective tissue membrane that is located at the entrance to the vagina. At the stage before puberty, this membrane performs a protective function, protecting the internal genital organs from being hit. However, in most cases, this membrane is not completely impermeable and is able to pass the menstrual blood formed during the period after puberty. The hymen usually ruptures during sexual intercourse, but in some cases it can be damaged in other conditions ( intense sports, cycling, injuries, masturbation using dildos or other objects).
• Clitoris. The clitoris is a structure similar in structure to the head of the male penis. It is located anterior to the small labia, close to the place of their connection. The size of the clitoris in an adult woman ranges from one to two centimeters. This organ is formed by two legs that are attached to the periosteum of the pelvic bones. The clitoris is an extremely sensitive organ capable of an erection - some increase in size during sexual arousal due to a rush of venous blood.
• The vestibule of the vagina and the external opening of the urethra. Between the clitoris and the entrance to the vagina is a triangular area, known as the vestibule of the vagina, which stretches all the way to the posterior junction of the labia minora. In this area is the external opening of the urethra, which is located about one centimeter anterior to the entrance to the vagina. In the same place, ducts of the skin glands open on both sides.
• Skin's and Bartholin's glands. Skin and Bartholin's glands, located at the opening of the urethra and at the back of the entrance to the vagina, are small organs that produce a substance that lubricates the vagina.

• vagina;

Vagina

Uterus

Anatomically, the uterus is divided into the following sections:

What age is the most common problem for younger women? The first signs may appear during the first pregnancy or immediately after birth. But when he is born at an earlier age, the recovery is already less complete.

What problems does this disorder cause? What are the possible complications without treatment? This causes women to feel self-esteem, inferiority. And it affects family relationships, sex life and female libido. If the problem worsens, and with age, when the connective tissues weaken, it is, and the problems deepen. Therefore, this problem must be addressed as soon as you begin to notice the first symptoms. This can help prevent many future health problems such as pelvic floor, decreased sexual satisfaction, urinary incontinence, physical activity, etc.

• Cervix. The cervix is ​​the lower part of this organ, which is the anatomical boundary between the vagina and the body of the uterus. The cervix is ​​a cylindrical muscular structure, through the center of which passes the cervical canal, which passes menstrual blood from the uterine cavity to the external environment, as well as sperm from the vagina to the uterine cavity. This channel is filled with a special mucus, which has some bactericidal properties, which protects the overlying genital structures from infections that often affect the vagina and external genitalia. The cervix under the influence of hormones during pregnancy ( or rather, hormones at the end of pregnancy) softens significantly, which leads to the expansion of the channel, making vaginal delivery possible. The average length of the cervix is ​​three to five centimeters.
• The body of the uterus. The body of the uterus is a small, rounded and dense muscular organ with relatively thick walls. In most cases, the body of the uterus deviates slightly anteriorly, but some anatomical differences may be observed. It should be noted that the posterior curvature of the uterus or excessive anterior curvature relative to the axis of the vagina can cause problems with conceiving a child. The average weight of the uterus in a non-pregnant and nulliparous woman is about 40 - 50 grams, while in women who have given birth, its weight is slightly larger - about 100 - 110 grams. During pregnancy, the uterus undergoes significant structural changes and increases in size to accommodate the fetus and amniotic membranes. Muscle contractions of the uterus that occur during childbirth ( so-called contractions), contribute to labor activity. If uterine contraction occurs before the due date, either premature birth or spontaneous abortion may develop. Excessive activity of the uterus during pregnancy in the absence of sufficient dilatation of the cervix can lead to hypoxia ( oxygen starvation) of the fetus, as well as to the rupture of the uterus itself.
• Isthmus. The isthmus is the narrow part of the uterus, located between the body and the cervix.

It should be noted that the dysfunction of the endometrium, whether it be hormonal changes in which the menstrual cycle is disturbed, or structural damage with the impossibility of proliferation and restoration of the mucous layer ( consequences of infectious processes, certain diseases or aggressive medical manipulations), is one of the common causes of female infertility.

Is it true that Pegel exercises can help? Do you really need an operation? Pegel's exercises, of course, are worth every woman. However, recent studies have shown that even when training with a trainer, not all women tense the muscles they need - that is, the pelvic floor. Regularity is also important. If you do the exercises occasionally, there will be no effect. Due to the busy pace of life, women forget, do not study, do not exercise properly.

However, even with perfect exercise, some women will experience urinary incontinence and some will not. This is due to the inherent inadequacy of the connective tissue inherent in the development of urinary incontinence. You should then seek medical attention for laser or surgical treatment. However, surgery is not always necessary - in case of mild to moderate urinary incontinence, it is enough to "give" a restorative laser procedure.

The fallopian tubes

The length of the fallopian tubes is approximately 10 centimeters, and the diameter is about ten millimeters. The end of the tube, located near the ovary, has specific outgrowths ( fringes), which are located around the ovary and serve to capture and transport the egg.

Which laser treatment for urinary incontinence is superior to others? Laser incontinence is painless, the results are quickly realized, it does not cause discomfort, straight from the office can return to daily work, and after a few weeks to have sex. However, if you develop urinary incontinence, you will need surgical treatment. Laser action is a tissue release of tissues, which leads to a decrease in the symptoms of complete recovery or severe urinary incontinence.

In laser-treated tissues, connective tissue molecules are reduced, which leads to a lifting, narrowing effect. The structures are shortened and their attachment points are not bone. Through contraction and tightening, the connective tissue lifts the bladder above it. The activated cells that synthesize collagen are also activated and the formation of new blood vessels is stimulated, thereby strengthening the connective tissue . This treatment is very effective when applied in a timely manner without disease.

In the structure of the fallopian tubes, the following segments are distinguished:

• Isthmus. The isthmus is a part of the tube, which is located in close proximity to the body of the uterus.
• Ampoule. The ampulla is the expanding part of the tube, which is the site of normal physiological fertilization ( penetration into the egg).
• Funnel. The funnel is the extreme part of the fallopian tube, on which the fringes described above are located.

The patency of the fallopian tubes depends on the following parameters:

Are all surgeries suitable for all women? Laser treatment for urinary incontinence is not suitable for all women. Unfortunately, it is not suitable for high-fat obesity with diabetes mellitus, many smokers, pregnant women. It also cannot be used until healing of acute inflammation, oncological diseases. All other women, regardless of age, can be successfully applied.

Are these procedures painful? Sexual relations are possible after a few weeks. At the same time, it is not allowed to swim in the bath, pool, lakes or other body of water, it is recommended that you do not carry more than 5 kg of weight for about 1 month after the procedure, avoid constipation for a couple of weeks, and do not use swabs for a month.

• Internal lumen of the fallopian tubes. If the internal lumen of the fallopian tubes decreases for any reason, this creates significant obstacles in the way of both spermatozoa and the egg. The most common causes of narrowing of the fallopian tubes are infectious processes ( ), which can be caused by both nonspecific infectious agents and pathogens of genital infections ( often). In addition, narrowing of the fallopian tube may be congenital. It should be noted that sometimes the fallopian tubes are tied up and dissected by women of their own free will, as one of the radical methods of contraception ( which, however, does not give a 100% guarantee).
• The mucous membrane of the fallopian tubes. Normally, the inside of the fallopian tubes is lined with cells that have cilia on the surface. The movements of these microscopic cilia create a wave that promotes the egg and sperm along the tube. A change in the cellular composition of the mucous layer or atrophy of these cilia can occur as a result of a local infectious process, as well as some hormonal disruptions.
• Contraction of the muscle fibers of the fallopian tubes. The fallopian tubes are formed by muscle fibers, which, when contracting, create a peristaltic wave that stimulates the advancement of an egg or a fertilized egg. This process is disturbed with an infectious lesion of the fallopian tubes.

The main causes of female infertility

Depending on the localization, the following causes of infertility are distinguished:

• cervical infertility;
• ovarian infertility;
• tubal infertility.

Cervical infertility

In addition, it should be noted that the cervical canal is filled with a special mucus, which greatly affects the movement of spermatozoa. Changing the properties of this mucus can cause female infertility. These changes cannot be detected by ultrasound, but they are determined during gynecological examination, by examining the viscosity of cervical mucus. It should be borne in mind that the properties of mucus change depending on the level of sex hormones, which fluctuate during the menstrual cycle.

Uterine infertility

The following congenital pathologies can cause uterine infertility:

• congenital underdevelopment or absence of internal female genital organs;
• the presence of a partition inside the cavity of the vagina or uterus;
• change in the shape or size of the internal cavity of the uterus;
• blind outgrowths in the walls of the body of the uterus.

• Endometritis. is an inflammatory disease that affects the lining of the uterus. It can develop as a result of the penetration of infectious agents, most often pathogens, and also as a result of trauma during childbirth, diagnostic or therapeutic, placement of intrauterine devices and other procedures. Inflammatory reaction, characteristic of endometritis, can cause the formation of intracavitary ( fibrous bands stretched between the inner walls of the uterus), which significantly reduce the uterine cavity, limit its functionality, and also interfere with the normal process of implantation. It should be noted that in some cases, endometritis can provoke complete atrophy of the uterine mucosa, thereby disrupting menstrual and reproductive functions.
• placental polyps. Placental are benign formations that develop on the basis of the remnants of the placenta, fragments of which could remain after a previous pregnancy. These outgrowths change the configuration of the uterus, limit its internal cavity, and disrupt the menstrual cycle. It should be noted that this pathology is quite rare and cannot be the cause of primary infertility ( since the presence of fragments of the placenta is assumed, which can form only after the development of pregnancy).
• Intracavitary and subserous myoma. is a benign tumor that disrupts the normal functioning of the uterus and can cause not only infertility, but also a number of other unpleasant symptoms, such as bleeding and pain. This pathology is quite common, but it is much more common among women in the period, which is associated with hormonal changes in the body. Among young women of reproductive age, this pathology is somewhat less common.
• Endometriosis. is a disease affecting women of reproductive age in which endometrial cells migrate into the pelvic cavity, attaching to the peritoneum, fallopian tubes, ovaries, or deeper layers of the uterus. At the same time, these cells continue to change cyclically during the menstrual cycle, thereby provoking pain, menstrual disorders, and infertility.
• Erosion, ulceration of the mucous membrane. and ulcers on the surface of the uterine mucosa can occur as a result of infection, inflammation, direct trauma, and also as a result of insufficient intake of essential nutrients and minerals into the body.

Ovarian infertility

The formation of cells, which are subsequently converted into eggs, begins in the early embryonic period - in the first trimester of the girl. At the same time, about seven million oocytes are laid ( eggs), which freeze at the first stage of fission. Subsequently, their number decreases and by birth is about two million. By puberty, only half a million oocytes remain. It is from them that adult eggs are formed during the reproductive age, ready to merge with the spermatozoon.

The maturation of eggs occurs under the action of hormones of the hypothalamic-pituitary-ovarian system. Every month, one egg and several follicular cells are formed from several developing oocytes, which surround the egg and perform the function of producing a number of sex hormones.

Violation of the process of formation and maturation of the egg can occur with pathologies of the menstrual cycle, when it does not occur due to hormonal disorders ( maturation and release of the egg).

Ovulation can be disturbed in the following pathologies:

• Chromosomal abnormalities. The process of egg maturation is associated with cell division, which is disrupted when the number of chromosomes changes. The fact is that during normal division of germ cells, ( structures that store genetic information) are distributed into daughter cells, however, a change in their number can cause disruption of this process. In addition, the presence of extra chromosomes, as well as their absence, is one of the reasons for changes in many internal organs, including the hormonal system. All this leads to the impossibility of developing a normal, fertile egg.
• Violation of the functioning of the hypothalamus. The hypothalamus is a brain structure that performs the function of controlling internal organs through regulation through the autonomic nervous system, as well as through the production of a number of specific hormones ( liberins and statins). These hormones are able to stimulate or block the production of other hormones, including sex hormones. As a result of dysfunction of the hypothalamus, a lack of sex hormones that regulate the menstrual cycle and the process of egg maturation develops, and infertility occurs.
• Hormonal disruptions. Changes in the level of sex hormones, as mentioned above, can cause menstrual and reproductive dysfunction. However, it should be noted that in the process of onset and maintenance of pregnancy, hormones of the pituitary gland also play an important role. A change in the concentration of substances produced by them can lead both to disruption of the processes of maturation of the egg, and to the impossibility of normal maintenance of pregnancy with the development of habitual ones.
• Structural changes in the ovaries. Change in the structure of the ovaries ( tumors, underdevelopment of the ovaries) leads to the impossibility of normal development and maturation of the egg.

tubal infertility

Other reasons

Often, infertility occurs as a result of the development of an immune reaction to the partner's sperm. This happens when the body is sensitized, which begins to attack foreign cellular elements - spermatozoa. As a result, the process of conception becomes impossible, as the number of sperm reaching the egg decreases. And, contrary to popular belief, one male reproductive cell is not enough for conception, since a special one contained in spermatozoa is needed to dissolve the protective shell of the egg.

Indications for ultrasound of the pelvic organs in infertility

In most cases, a gynecologist prescribes an ultrasound examination. However, this can be done by another specialist who deals with the treatment of infertility of a married couple. In some cities, there are even separate reproductive centers or family centers, in which the efforts of medical personnel are aimed at resolving the problem of infertility and providing maximum assistance in conceiving a healthy child.

It should be understood that ultrasound can detect only macroscopic structural changes. For this reason, it is not prescribed for suspected functional disorders. However, it should be noted that changes in the endometrium visible on ultrasound are a direct indicator of menstrual dysfunction, which can occur both against the background of structural and against the background of functional disorders.

Ultrasound examination of the pelvic organs allows you to identify the following indicators:

• the size and shape of the uterus;
• the structure of the muscular layer of the uterus;
• length of the cervix;
• condition of the cervical canal;
• condition of the vaginal part of the cervix;
• the structure and growth of the endometrium throughout the menstrual cycle;
• endometrial thickness;
• position of the ovaries;
• the size of the ovaries;
• the structure of the ovaries;
• structure of the fallopian tubes.

• fibroleiomyoma of the body of the uterus or uterine cervix ( benign tumor);
• endometriosis;
• , polyps, or inflammation of the endometrium ( uterine mucosa);
• erosion, ulcers, cysts of the uterus and cervix;
• and ovarian tumors
• inflammation of the fallopian tubes;
• accumulation of fluid in the lumen of the fallopian tubes hydrosalpinx);
• adhesions in the pelvic cavity;
• scars of the body of the uterus.

Research methodology

When conducting an ultrasound examination, a special sensor is used, which is also an emitter of sound waves. The phenomenon of sound generation is based on the piezoelectric effect, that is, on the phenomenon of oscillations in special crystals when an electric current of a certain frequency is passed through them. These waves propagate deep into the tissues, and then the sensor registers their reflection.

When examining the female reproductive system, several types of sensors can be used, which differ in the type of sound beam they form. It should also be noted that there are two main research methods - transabdominal and transvaginal. Transvaginal examination involves the introduction of a sensor through the vagina, which allows you to better study the internal structure of the genital organs. Transabdominal examination involves applying the sensor to the skin in the abdomen. This method is used much more often, but it depends on the condition of the organs adjacent to the uterus and ovaries - the bladder and intestines.

Thus, in the study of female internal genital organs, preparation of the intestines and bladder is necessary. For this purpose, before the study, carminatives are usually prescribed, that is, drugs that reduce gas formation in the gastrointestinal tract. To do this, two to three days before the study, capsules, simethicone, plantex or herbal preparations of sage, mint, oregano are prescribed. In addition, it is recommended to exclude from products that increase gas formation ( fresh vegetables, fruits, cabbage, beans, carbonated drinks, kvass, beer). Since a full bladder improves the conduction of sound waves to the pelvic cavity and optimizes the examination of the ovaries and uterus, it is recommended to drink plenty of fluids immediately before the examination.

Ultrasound of the uterus

It must be understood that many parameters in the study of the uterus depend on the phase of the menstrual cycle, physique, number of pregnancies and childbirth. In addition, there may be some individual features in the structure of the internal female genital organs. For this reason, the interpretation of the results of the study, based solely on the indications of ultrasound, is incorrect, since a complete diagnosis requires a history of previous diseases, an obstetric and gynecological history, as well as an assessment of the general condition of the body.

The main parameters in the study of the uterus

The most common causes of infertility detected by ultrasound are the following pathologies of the uterus:

• Endometrial polyps. Endometrial polyps develop as multiple benign pedunculated tumors that consist of overgrown endometrium. In most cases, they are asymptomatic or are accompanied by uterine bleeding, infections, pain, and infertility. On ultrasound, they are best seen in the first half of the menstrual cycle or in the second half after the preliminary injection of a contrast agent into the uterine cavity. Appear as hyperechoic light) structures in the uterine cavity.
• Intrauterine adhesions. Adhesions in the uterine cavity develop as a result of damage to the basal layer of the endometrium and are dense fibrous bands that limit the uterine cavity. Characterized by the absence of a menstrual cycle or scant menstrual flow. Best visualized during menstruation ( if any), when the exfoliating endometrium envelops them and, thus, contrasts, as it were. On ultrasound, they are detected as hyperechoic bridges between the walls of the uterus.
• Endometriosis. Endometriosis, as described above, is a pathological situation in which endometrial areas are outside the internal cavity of the uterus. Most often, the germination of the endometrium in the muscular layer of the uterus is observed. The disease manifests itself with pelvic pain, disturbed menstrual cycle and copious discharge during menstruation. Ultrasound examination reveals an enlarged uterus, which, however, may be of normal size. The muscular layer of the uterus acquires the aspect of "Swiss cheese" with multiple hypoechoic ( dark) zones, as well as with traces of bleeding and. Sometimes the entire wall of the uterus becomes less dense with occasional large cysts.
• hyperplasia of the endometrium. Hyperplasia ( overgrowth) of the uterine mucosa may occur as a result of excessive stimulation by the female sex hormone estrogen. In this case, an increase in the thickness of the endometrium is observed.
• Malignant tumor of the endometrium. Malignant tumor of the endometrium endometrial carcinoma) is a severe oncological pathology that occurs mainly in the postmenopausal period, but can also develop in reproductive age. Ultrasound reveals hyperechoic masses in the uterine cavity, thickening of the endometrium, free fluid in the uterine cavity and small pelvis, and sometimes destruction of the mucous and submucosal layers.
• Leiomyoma ( uterine fibroids). Leiomyoma is the most common benign tumor of the uterus, occurring in almost a quarter of women of childbearing age. It is an overgrown smooth muscle tissue that can grow into the uterine cavity, into the wall of the uterus, or into the pelvic cavity. An ultrasound examination reveals an increase in the size of the uterus, a change in the contour of the uterus. A formation can be detected, the acoustic density of which depends on the content of muscle and connective tissue fibers.
• Anomalies in the structure and shape of the uterus. With some congenital pathologies, additional cavities, partitions and other abnormal formations can be detected in the uterus. Sometimes the uterus may be completely absent or underdeveloped. All this is quite easily detected by ultrasound.

Ultrasound of the fallopian tubes

The main parameters in the study of the fallopian tubes

It should be noted that the optimal period for ultrasound of the fallopian tubes is the period immediately after ovulation, since the fluid secreted by the follicle facilitates their visualization.

Most often, with infertility, the following pathologies of the fallopian tubes are detected:

• Salpingitis. Salpingitis is an inflammatory process that covers the fallopian tubes on one or both sides. In the initial stages, an ultrasound examination may not reveal any pathological abnormalities, however, in the future, thinning of the wall of the fallopian tubes is revealed, a change in their contour, which becomes less clear and smooth. Sometimes echogenic formations are detected in the lumen of dilated tubes, which in most cases indicates pyosalpinx, a purulent-infectious process.
• Benign tumor. Benign tumors ( leiomyomas) of the fallopian tubes are quite rare, despite the same embryonic origin of the tissues of the uterus and tubes. Overgrown muscle fibers can cause narrowing or closure of the tube lumen, thereby provoking infertility. An ultrasound examination reveals a dense formation in the fallopian tube, the acoustic density of which, as in the case of uterine fibroids, depends on its tissue composition. Quite often, these tumors have a heterogeneous structure.
• Malignant tumor. Malignant tumor of the fallopian tubes is the rarest type of cancer in gynecological practice. This pathology is manifested by pain, bleeding and the release of whitish contents from the genital tract. An ultrasound revealed a heterogeneous spindle-shaped mass located in the area of ​​​​the uterine appendages.
• Narrowing of the lumen of the fallopian tube. To study the lumen of the fallopian tubes, a special contrast agent is used, which is injected under sterile conditions through a special catheter into the uterine cavity and rises through the fallopian tubes. This method allows you to better visualize the inner lumen of the pipe, its contours and, most importantly, the permeability.

ovarian ultrasound

The features of these two methods are:

• With transabdominal access it is desirable that the bladder at the time of the study was full. This will facilitate the passage of sound waves through the tissues and make the study more accurate. The recommended wave frequency is 3.5 - 3.75 MHz.
• Transvaginal examination does not require bladder filling. The transducer is brought closer to the ovaries than with transabdominal access. The recommended wave frequency is from 5 to 10 MHz. This version of the procedure is more reliable and informative. It requires a higher qualification of the doctor who conducts the study. The fact is that many anatomical structures turn out to be “inverted” in the resulting image. Because of this, an inexperienced specialist may experience some difficulties.

The main parameters for examining the ovaries

Causes of poor visualization of the ovaries can be:

• inadequate filling of the bladder optimal filling - when in the picture the edge of the bladder overlaps the bottom of the uterus);
• abnormal position of the ovaries ( their insufficient descent into the abdominal cavity, location behind the uterus or in the inguinal canal);
• pathological underdevelopment of the ovaries ( Turner's syndrome, certain diseases of the pituitary gland);
• excessive accumulation of gas or contents in bowel loops;
• the presence of scars after surgery in the pelvic area.

Most often in women with infertility, the following abnormalities can be detected on ultrasound:

• Pathological ovarian cysts. If the ovarian cyst on ultrasound reaches more than 5 cm in diameter, we can talk about pathology. In addition, hemorrhage may occur in the cavity of the Graafian vesicle. Then its contents become more echogenic. A cyst is formed.
• Thecalyutein cyst. Such formations reach 8-10 cm in diameter and are most often caused by simultaneous pathological processes in other organs ( with choriocarcinoma, hydatidiform mole, etc.). These cysts may be bilateral. On ultrasound, several chambers are often found in their cavity.
• ovarian tumor. As a rule, ultrasound cannot accurately determine the nature of the tumor or even tell if it is benign or malignant.
• Torsion of the ovary. Ultrasound usually reveals an enlarged ovary ( up to 5 - 7 cm), free fluid may be found in the abdominal cavity due to the inflammatory process.
• Oophoritis. In acute inflammation, the ovary is significantly enlarged in size, its contours are clearly visible, but echogenicity is reduced. With the formation of areas of necrosis and pus, point formations with increased echogenicity are visible. In chronic cases, the structure of the organ may be heterogeneous. The dimensions are usually within the normal range.
• Ovarian apoplexy. The echogram clearly shows the place of the rupture. There, the contour of the enlarged ovary is abruptly interrupted. It is difficult to confirm the exact diagnosis only with the help of ultrasound.
• Endometriosis of the ovary. The contour of the organ is fuzzy, echogenicity is different in different areas. Multiple small cysts are found that change the shape of the organ, the surface may be bumpy. In this case, endometriosis is difficult to distinguish from polycystic ovaries.
• Polycystic ovary. The process is usually two-way. Organs increase 3-5 times compared to the norm. The contour of the ovary is easy to discern. Inside, multiple formations with a diameter of 1.5–2 cm are found.

The pelvic organs are located in the anatomical space, limited by the bones of the small pelvis. What organs are here? First of all, it depends on whether the body belongs to a woman or a man. Let's take a look in detail which organs are located in the female, male body, as well as which organs are present in both organisms.

Internal organs of the small pelvis of a woman and a man

Rectum

Both female and male pelvic organs include this part of the colon. It accumulates and then removes digestive waste from the human body. The length of the rectum in an adult is 15 cm, and its diameter is 2-8 cm. Behind it is the coccyx and sacrum.

Bladder

It is located behind the pubic symphysis and is separated from it by loose fiber, which is located in the space behind the pubis. The top of the bladder, when it is filled, comes into contact with the abdominal anterior wall and begins to protrude above the symphysis. It should be noted that the proximity of the pelvic organs has a certain effect on their functions. So, if one of the organs is diseased, the disease can affect the condition of neighboring organs.

Female pelvic organs

Ovary

This organ is paired. In the ovaries, the eggs mature and then develop. In addition, female sex hormones are formed here, which subsequently enter the blood and lymph. The ovary has a slightly pinkish color, and its surface passes into a convex posterior edge and into the mesenteric edge in front. Considering the structure of the pelvic organs of a woman, one can notice rudimentary formations located near each ovary. The ovarian appendage is located among the sheets of the mesentery of the fallopian tube. It consists of transverse grooves and a longitudinal duct of the appendage. Near the tubal end of the ovary, in the mesentery of the fallopian tube, lies the periovary - a small formation, consisting of several blind tubules separated from each other.

Uterus

The pelvic organs of a woman include an unpaired pear-shaped muscular organ. It is located in the middle part of the pelvic cavity, behind the bladder and in front of the rectum. The bottom of the uterus protrudes slightly above the line of confluence of the fallopian tubes. It has a convex shape. The body of the uterus is the middle part of the organ and has a conical shape. In the lower part, it narrows and smoothly passes into the cervix, the lower part of which protrudes into the vaginal cavity.

Vagina

This is a complete unpaired organ located in the space from the uterus to the genital slit. It has a tubular shape, slightly curved at the back. Its upper end originates from the cervix, then goes down, where its lower end opens with a vaginal opening, after which it passes through the urogenital diaphragm. It should be noted that the length of the vagina is about 10 cm, and the thickness of its walls is 3 cm.

Male pelvic organs

seminal vesicle

It is a paired organ located on the side and behind the bladder, as well as on top of the prostate gland. The seminal vesicle is a secretory organ. Its length is about 5 cm, width is about 2 cm, thickness is 1 cm. In the context, this organ looks like bubbles communicating with each other. Here the vas deferens joins the excretory duct, where they form the ejaculatory duct. Its length is about 2 cm, and the width of the lumen at the beginning is 1 mm; at the urethra - only 0.3 mm.

Prostate

The male pelvic organs also include such a muscular-glandular unpaired organ as the prostate gland. She secretes the secret that is part of the sperm. The prostate gland is located under the bladder, in the lower anterior part of the small pelvis. The beginning of the urethra and both ejaculatory ducts pass through this organ. The longitudinal size of the prostate gland is 3 cm, the transverse size is 4 cm, and its thickness is 3 cm.

Also in the pelvis is a lot of connective tissues that hold the organs in place. The health of all these organs is very important for the body, since they are all located very close and can have a negative effect on each other if one of them becomes ill. Now you yourself know very well which organs are located in the pelvic area. This information can help you protect your health!

Operative surgery: lecture notes I. B. Getman

LECTURE No. 10 Topographic anatomy and operative surgery of the pelvic organs

LECTURE #10

Topographic anatomy and operative surgery of the pelvic organs

Under the "pelvis" in descriptive anatomy is meant that part of it, which is called the small pelvis and is limited to the corresponding parts of the ilium, ischium, pubic bones, as well as the sacrum and coccyx. At the top, the pelvis communicates widely with the abdominal cavity, at the bottom it is closed by the muscles that form the pelvic diaphragm. The pelvic cavity is divided into three sections, or floors: peritoneal, subperitoneal, subcutaneous.

The peritoneal region is a continuation of the lower floor of the abdominal cavity and is delimited from it (conditionally) by a plane drawn through the pelvic inlet. In men, in the peritoneal part of the pelvis, the part of the rectum covered by the peritoneum, as well as the upper, partially posterolateral and, to a small extent, the anterior wall of the bladder, are located. Passing from the anterior abdominal wall to the anterior and upper walls of the bladder, the peritoneum forms a transverse cystic fold. Further, the peritoneum covers part of the posterior wall of the bladder and, in men, passes to the rectum, forming the rectovesical space, or notch. From the sides, this notch is limited by rectovesical folds stretched in the anteroposterior direction between the bladder and the rectum. In the space between the bladder and the rectum, there may be part of the loops of the small intestine, sometimes the sigmoid colon, less often the transverse colon. In women, the same parts of the bladder and rectum as in men, and most of the uterus with its appendages, wide uterine ligaments and the upper part of the vagina are placed in the peritoneal floor of the pelvic cavity. When the peritoneum passes from the bladder to the uterus, and then to the rectum, two peritoneal spaces are formed: the anterior (vesicouterine space); posterior (rectal-uterine space).

When moving from the uterus to the rectum, the peritoneum forms two folds that stretch in the anteroposterior direction and reach the sacrum. They are called sacro-uterine folds and contain ligaments of the same name, consisting of muscular-fibrous bundles. In the recto-uterine space, intestinal loops can be placed, and in the vesico-uterine space - a greater omentum. The recto-uterine recess (the deepest part of the peritoneal cavity in women) is known in gynecology as the pouch of Douglas. Here, effusions and streaks can accumulate during pathological processes both in the pelvic cavity and in the abdominal cavity. This is facilitated by the mesenteric sinuses and canals mentioned in the previous lecture.

The left mesenteric sinus of the lower floor of the abdominal cavity continues directly into the pelvic cavity to the right of the rectum.

The right mesenteric sinus is delimited from the pelvic cavity by the mesentery of the terminal portion of the ileum. Therefore, the accumulations of pathological fluid formed in the right sinus are initially limited to the boundaries of this sinus and are sometimes encapsulated without passing into the pelvic cavity.

Inspection of the peritoneal pelvis and organs located there can be performed through the anterior abdominal wall by lower laparotomy or using modern endovideoscopic (laparoscopic) methods. The endoscope can also be inserted through the posterior fornix of the vagina.

Among the urgent surgical interventions in the peritoneal floor of the pelvis, operations for complications of ectopic pregnancy are among the most frequent. Ectopic pregnancy is one of the main causes of internal bleeding in women of childbearing age.

Access to the peritoneal floor of the pelvis in a disturbed ectopic pregnancy can be either "open" (laparotomy) or "closed" (laparoscopy).

In the first case, a lower median or lower transverse laparotomy is used for access. After performing access to the wound, the fallopian tube is removed and the place of its rupture is determined. Apply a Kocher clamp to the uterine end of the tube (at the corner of the uterus). The second clamp captures the mesosalpinx. Scissors cut off the tube from her mesentery. Ligatures are applied to the vessels and the uterine end of the tube. The stump of the tube (corner of the uterus) is peritonized using the round ligament. Liquid blood and blood clots are removed from the abdominal cavity. Produce an audit of the pelvic organs and sutured the surgical wound.

The second floor (subperitoneal) is enclosed between the peritoneum and the sheet of the pelvic fascia, which covers the muscles of the pelvic floor. Here, in men, there are retroperitoneal (subperitoneal) sections of the bladder and rectum, the prostate gland, seminal vesicles with their ampullae, and the pelvic sections of the ureters.

In women, the same sections of the ureters, bladder and rectum as in men, as well as the cervix, the initial section of the vagina. The internal and external iliac arteries, passing in the subperitoneal pelvis, are branches of the common iliac arteries. The place of division of the abdominal aorta into the right and left common iliac arteries is more often projected onto the anterior abdominal wall at the intersection of the midline with the line connecting the most protruding points of the iliac crests, but the level of bifurcation often varies from the middle of the III to the lower third of the V lumbar vertebrae.

Various methods of vascular surgery (prosthesis, shunting, endovascular methods, etc.) are used for the surgical treatment of diseases of the aorta of the iliac or iliac-femoral segments of the arteries of the lower limb.

In operative gynecology, situations sometimes arise that require ligation of the internal iliac artery. Depending on the indications, it is possible to conditionally distinguish between emergency and planned ligation of the internal iliac artery. The need for emergency dressing may arise with massive bleeding, uterine rupture, crushed wounds of the gluteal region, accompanied by damage to the upper and lower gluteal arteries. Planned ligation of the internal iliac artery is performed as a preliminary stage in cases where the upcoming threatens the possibility of massive bleeding.

Ligation of the internal iliac artery is a complex and risky procedure. When applying ligatures to the iliac arteries, as well as during operations on the pelvic organs, especially when removing the uterus and its appendages, one of the serious complications is damage to the ureters. Treatment of ureteral injuries is almost always surgical. The primary suture of the ureter is rarely used, only for surgical injuries recognized during surgery. In the primary surgical intervention, they are limited to diversion of urine by nephropyelostomy and drainage of urinary streaks. After 3-4 weeks after the injury, a reconstructive operation is performed.

During the operation of ureteroanastomosis, the ends of the damaged ureter are connected by several interrupted catgut sutures. For the purpose of diverting urine, sewing the end of the ureter into the intestine or removing it to the skin (palliative surgery) is sometimes used.

With low ureteral injury in the pelvis, ureterocystoanastomosis should be considered the method of choice, which can be performed in various ways. This operation requires high professional technique and is usually performed in specialized clinics.

With urinary retention and the inability to perform catheterization (urethral injury, burns, prostate adenoma), a suprapubic puncture of the bladder can be performed. The puncture is made with a long thin needle (diameter 1 mm, length 15–20 cm) 2–3 cm above the symphysis. If necessary, the puncture can be repeated.

For long-term and permanent diversion of urine, thoracic puncture of the bladder can be used. Puncture of the bladder during thoracic epicystostomy is performed 3-4 cm above the pubic symphysis with the bladder filled with 500 ml of an antiseptic solution. After removing the stylet, a Foley catheter is inserted into the bladder cavity along the trocar sleeve, which is pulled up to a stop and tightly fixed with a silk ligature to the skin after the trocar tube.

During the operation of the suprapubic vesical fistula, drainage is installed in the lumen of the bladder. Access to the bladder - median, suprapubic, extraperitoneal. The bladder incision around the drainage tube is sutured with a double-row catgut suture. The wall of the bladder is fixed to the muscles of the abdominal wall. Then the white line of the abdomen, subcutaneous tissue and skin are sutured. The drainage tube is fixed with two silk sutures to the skin.

Fascia and cellular spaces of the pelvis. Purulent inflammatory processes that develop in the cellular spaces of the small pelvis are particularly severe. For drainage of abscesses in the cellular spaces of the subperitoneal pelvis, various accesses are used depending on the localization of the focus. The introduction of drainage can be carried out either from the side of the anterior abdominal wall, or from the side of the perineum.

To access the subperitoneal cellular spaces of the pelvis from the side of the abdominal wall, incisions can be made:

1) in the suprapubic region - to the prevesical space;

2) above the inguinal ligament - to the paravesical space, to the parametrium.

Perineal accesses can be performed using incisions: along the lower edge of the pubic and ischial bones; through the center of the perineum anterior to the anus; along the perineal-femoral fold; behind the anus.

The third floor of the pelvis is enclosed between the sheet of the pelvic fascia, which covers the pelvic diaphragm from above, and the skin. It contains parts of the organs of the genitourinary system and the final section of the intestinal tube passing through the pelvic floor, as well as a large amount of fatty tissue. The most important is the fiber of the ischiorectal fossa.

Topographically, the lower part of the pelvis corresponds to the region of the perineum, the frontiers of which are the pubic and ischial bones in front; from the sides - ischial tubercles and sacrotuberous ligaments; behind - coccyx and sacrum. The line connecting the ischial tubercles, the perineal region is divided into the anterior section - the genitourinary triangle and the posterior - anal triangle. In the anal perineum there is a powerful muscle that lifts the anus and a more superficially located external sphincter of the anus.

The lateral walls of the fossa are: the lateral-internal obturator muscle with the fascia covering it; the medial-inferior surface of the levator ani muscle, the fibers of which run from top to bottom and from outside to inside towards the anus. The fiber of the ischiorectal fossa is a continuation of the subcutaneous fat layer.

Inflammation of the perirectal tissue, which is part of the tissue of the ischiorectal fossa, is called paraproctitis.

According to localization, the following types of paraproctitis are distinguished: subcutaneous submucosal, ischiorectal, pelviorectal. With paraproctitis, surgical intervention is indicated. Drainage incisions are made depending on the location of the abscess.

Low-lying submucosal paraproctitis can be opened through the wall of the rectum. With subcutaneous paraproctitis, an arcuate incision is recommended, bordering the external sphincter of the anus, sometimes a longitudinal incision is made between the anus and the coccyx along the midline of the perineum (with abscesses behind the rectal tissue).

For drainage of deeply located abscesses of the ischiorectal fossa, an incision is made along the branch of the ischium and penetrate into the depth along the outer wall of the fossa.

If it is necessary to drain the pelviorectal space, the fibers of the levator ani muscle are stratified from the indicated access, and a thick drainage tube is inserted into the purulent cavity. The pelviorectal cellular space can also be drained from the side of the anterior abdominal wall by an incision above the inguinal ligament. Less commonly, for drainage of the ischiorectal fossa, access is made from the side of the thigh through the obturator foramen. To do this, the patient is placed on the edge of the table in a position for perineal operations. The thigh is retracted outward and upward until the fine muscle is tense. Departing from the inguinal fold down by 2 cm, an incision of the skin and subcutaneous tissue 7–8 cm long is made along the edge of this muscle. After dissection of the skin and subcutaneous tissue, the thin muscle is retracted upward. The adjacent short adductor muscle is also retracted upward. The large adductor muscle moves downward. The external obturator muscle is stratified in a blunt way and moved apart to the sides, the muscle is dissected at the lower inner edge of the obturator foramen. After emptying the abscess, an elastic tube with side holes is inserted into the ischiorectal fossa.

Lecture No. 1. Anatomy and physiology of the female genital organs 1. Anatomy of the female genital organs The genital organs of a woman are usually divided into external and internal. The external genitalia are the pubis, the labia majora and minora, the clitoris, the vestibule of the vagina, the virgin

3. Anatomy of the female pelvis The structure of the bone pelvis of a woman is very important in obstetrics, since the pelvis serves as the birth canal through which the fetus is being born. The pelvis consists of four bones: two pelvic, sacrum and coccyx. Pelvic (nameless) bone

4. Anatomy of the female pelvis The structure of the bone pelvis of a woman is very important in obstetrics, since the pelvis serves as the birth canal through which the fetus is being born. The pelvis consists of four bones: two pelvic, sacrum and coccyx. Pelvic (nameless) bone

27. Topographic anatomy and operative surgery of the thyroid gland The thyroid gland consists of two lateral lobes and an isthmus. The lateral lobes are adjacent to the lateral surfaces of the thyroid and cricoid cartilages and the trachea, reaching the lower pole of 5-6 tracheal rings